Patient History Form. Middle: Last: DOB: Maiden Name: SS#: Occupation: Street Address: City: State: Zip: Reason for today s visit:

Transcription

1 TODAY S DATE: Patient History Form First: Middle: Last: DOB: Maiden Name: SS#: Occupation: Street Address: City: State: Zip: Reason for today s visit: How did you hear about our practice? Please complete below. Check box below for preferred call, , or text for your office confirmation: : Preferred Lab: Quest Labcorp Other Preferred Radiology: Preferred Pharmacy: Primary Care Physician: Referring Physician: Name Location Name Location Name Phone # Name Phone # Disclaimer: The United States Federal Government has established criteria for meaningful use of electronic medical records. Each provider needs to show that they are using the electronic medical record technology in a way that can be measured significantly in quantity and quality. We are therefore required to ask certain questions which pertain to your personal history and social behaviors. You as an individual have the option to decline to answer. Preferred Language: Please Check the Appropriate Box

2 Documentation of receipt of Notice of Privacy Practices Effective September 23, 2013 HIPAA Disclosure Information Hunterdon Gastroenterology Associates reserve the right to modify the privacy practices outlined in this notice. Upon request, you may obtain a paper copy of this Notice. Yes, I have received a copy of the Notice of Privacy Practices for Hunterdon Gastroenterology Associates. No, at this time I have declined a copy of the Notice of Privacy Practices for Hunterdon Gastroenterology Associates and understand that at anytime I can request a written copy of this Notice. Print Name Date of Birth Signature of Parent or Legal Guardian (If patient is under the age of 18 or POA) Medical Information Consent Should I not be available, I give Hunterdon Gastroenterology Associates permission to release my medical information to the following person(s): Any health care provider or facility. (please list physician or facility). Family (please provide names) Parent Spouse Child Sibling Other I choose to receive voice messages on the telephone or answering machine. I choose not to have my medical information released to anyone but myself. Print Name Signature of Parent or Legal Guardian

3 (If patient is under the age of 18 or POA) 1100 Wescott Drive, Suite 204, 206, 207, Flemington, NJ West End Avenue, Somerville, NJ (908) Patient or Responsible Party: Please acknowledge your consent and understanding of the following terms regarding patient care at Hunterdon Gastroenterology Associates and Hunterdon Endosurgery Center (herein known as HGA/HEC) by initialing and signing where indicated. Please contact our billing department with any questions. Terms and Policies Authorizing the Release of Information: I authorize HGA/HEC to release any necessary medical records to the appropriate parties (insurance, pharmaceutical companies, etc.) in relation to determining responsibility for medical benefits and obtaining reimbursement for professional services. Professional Fees: I understand that I am financially responsible for any and all charges for professional services, whether or not paid by an insurance carrier or health plan. Exceptions are when patient financial responsibility is limited by statutory regulation such as Medicare or by managed care (HMO, PPO, etc.) contract. In cases submitted to my insurance carrier, it is my responsibility to financially cover any deductibles, co-payments, and non-covered services as stipulated by my specific insurance plan. I may request that payment of my authorized benefit be made on my behalf and assigned to HGA/HEC. Any payment/explanation of benefits issued directly to me for care received at HGA/HEC must be forwarded to HGA/HEC in a timely fashion for posting of payment and/or appropriate adjustment. Managed Care: To validate your managed care agreement/fee schedule, proof of your insurance coverage and personal identification must be provided at the time of service, along with necessary authorizations/referrals. All associated co-payments and deductibles will be collected at the time of visit. Without proper documents, you may be required to pay in full. Referrals: If my insurance plan requires a referral, it is my responsibility to obtain and present the referral at the time of service. If one is not obtained, I may be responsible for payment in full. Collection Agency: If my account is over 90 days past due, a letter will be sent stating that I have 20 days to pay the account in full. Partial payments will no longer be accepted unless negotiated by the billing department. If the balance continues to remain delinquent, I may be sent to a collection agency where a collection fee of $50.00 or 20% (whichever is greater) will be added to the unpaid balance. The practice may also discharge me from the practice for non-payment. Forms: Requests for completion of disability forms, reports, or other paperwork will require an advance fee based on the complexity of the form. Please allow 5 business days for completion. Release of Medical Records: Medical records copies require written authorization and prepaid fees related to preparation. Please allow 10 days for copies. Missed Appointment/Procedure: I acknowledge that I am responsible for any missed appointments or any cancelled appointments in which a 24 hour notice was not given. The fee for a missed office appointment in HGA is $ HEC requires 48 hour notice of cancelling a procedure and the fee for a missed procedure is $ for each procedure. Returned check fee: I understand that there will be a $25.00 fee for all returned checks. Divorced Parents of Minor Patients: The adult who signs a minor patient into our practice on the day of service accepts responsibility of payment or communication. It is the responsibility of both parents to communicate with each other about payment issues. Patient balance credits of $15.00 or less will be kept on file for future use unless requested by patient. Initials Printed name of the patient Patient Date of Birth Signature of the Patient or Guardian Date Printed name of the Guardian

4 Patients Responsibilities for Follow Up Care Pledge I, (Print name), hereby acknowledge and understand that even with the best training, skill and experience, a medically trained professional is not always capable of solving my medical problems. Therefore, I understand it is important that any and all recommendations by doctors are followed completely in order to increase the likelihood of a positive and healthy treatment/outcome. I acknowledge and understand that if any physician in this office prescribes medicine to me that the proper taking of any such medicine shall be my sole responsibility (or my guardian who has attended this consultation). I agree to properly follow the prescribed dosage and frequency amounts of these medicines as recommended by my doctor. I understand that if a doctor in this office refers me to see another doctor or receive another test including, but not limited to, a blood test, and MRI, or CT scan, this timely recommendation is important and essential to the ultimate success of my treatment/outcome. I understand that it is not possible for any person in this office to constantly follow-up to ensure that I have followed these recommendations. Therefore, I understand that if I fail to see that specialist or obtain the test for which I was referred immediately, this can risk my current health or increase future health risks. I understand that it is solely my responsibility to follow any of the medical advice given by any medical person in this office and any bad health outcome from my failure to follow the advice of my doctors should be expected. Patient Name Date of Birth Date

5 Nextgen Unified Chart Opt In Status I hereby choose to participate in the Nextgen Unified Electronic Medical Record. I understand that the information contained in my Electronic Medical Record WILL BE SHARED electronically with other providers and affiliates that are involved in my care at Hunterdon Healthcare. I also understand that information contained in my Electronic Medical Record will be available to the Hunterdon Medical Center Emergency Department in the event of an emergency. I also understand that by disclosing my address in my Electronic Medical Record I am authorizing consent to receive and send HIPAA Compliant s through Hunterdon Healthcare s Nextgen Patient Portal. These s will be sent and received by the providers and affiliates involved in my care at Hunterdon Healthcare. I was also given a letter from the practice explaining what Unified Chart and Patient Portal is and have been given the opportunity to ask questions at this time. I also understand that I will be given the opportunity to discuss my option to Opt In or Opt Out of Unified Chart with my physician. : Date of Birth: Patient Name or Guardian Name (Please Print): Patient or Guardian Signature: Staff Initials: